Basic Information
| Provider Information | |||||||||
| NPI: | 1083840565 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GUSTAFSON | ||||||||
| FirstName: | CHERYL | ||||||||
| MiddleName: | JANENE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 24325 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981240325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 0623275462 | ||||||||
| FaxNumber: | 5033628435 | ||||||||
| Practice Location | |||||||||
| Address1: | 3216 NE 45TH PL STE 101 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981054028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2065251168 | ||||||||
| FaxNumber: | 2065251169 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2009 | ||||||||
| LastUpdateDate: | 01/29/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | 01075298A | IN | N | Allopathic & Osteopathic Physicians | Dermatology | 207ND0101X | MD60757392 | WA | Y | Allopathic & Osteopathic Physicians | Dermatology | MOHS-Micrographic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 2084320 | 05 | WA | MEDICAID |